CURRENT COMPLAINT, INJURY AND PAIN QUESTIONNAIRE

CURRENT COMPLAINT, INJURY AND PAIN QUESTIONNAIRE


CURRENT COMPLAINT, INJURY AND PAIN QUESTIONNAIRE

Your Name: ______________________________ Date: ___________

1. Describe the accident or circumstances which led up to your injury
and resulting pain.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


2. When and where did you first become aware of the pain
associated with the injury? _____________________________________
___________________________________________________________


3. In what part or parts of your body does the pain first occur?
___________________________________________________________


4. In what part or parts of your body does the pain now occur?
___________________________________________________________


5. Has the pain ever been localized? ____ If so, where? ______________


6. Describe as best you can how the pain feels to you (include in your
answer the severity of the pain, whether the pain is continuous or
intermittent, how long it lasts, and whether it ever changes).
___________________________________________________________
___________________________________________________________


7. Are there any circumstances which either intensify or lessen the
pain? _____ If so, please describe in detail. _______________________
____________________________________________________________________________
____________________________________________________________________________
______________________

8. Does the pain lead to any other difficulties (e.g., inability to move
your arms or legs, headaches, nausea, irritability)? _____ If so, explain.
__________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
______________________


9. Does the pain ever interfere with your daily activities? _____ If so,
please explain in detail.
____________________________________________________________________________
____________________________________________________________________________
______________________


10. Do you ever have to stop your activities to alleviate the pain? _____
If so, please explain.
__________________________________________________________


11. Do you ever have to lie down and rest to alleviate the pain? ________
If so, please explain when and how often.
__________________________________________________________

12. Do you ever have to take off from work because of the pain?________ If
so, please explain how often this happens.
____________________________________________________________________________
________________________________________


13. Has anything helped to lessen the pain (e.g. medication, relaxation,
massage, rest, counseling)?
__________________________________________________________
__________________________________________________________


14. If so, how long does it take for these remedies to work?
__________________________________________________________


15. How long do these remedies last before the pain returns?
__________________________________________________________


16. What have you told your doctor about your pain? ________________
____________________________________________________________________________
________________________________________


17. Has any doctor ever told you that you are imagining your pain?____ How
did you feel when you were told?
__________________________________________________________
What did you say in response? __________________________________
____________________________________________________________________________
________________________________________

18. Has any doctor told you the cause of your pain? ____ If so, what did
he say? ___________________________________________________
__________________________________________________________


19. Are you satisfied with the doctor's explanations, or do you think the
pain is due to some cause or reason other than what the doctor has told you?
____________________________________________________________________________
________________________________________


20. List all persons you have consulted for treatment of your pain and
injury. If any of these persons are doctors, specify their specialties
(e.g., cardiologist, internist, neurologist, orthopedist, chiropractor,
osteopath, psychologist, plastic surgeon).
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
______________________________________________________________


21. Has any doctor recommended an operation to alleviate the pain? ____ If
so, please state the doctor's name and address, and when the recommendation
was made.
____________________________________________________________________________
____________________________________________________________________________
______________________


22. Have you had any operations for your pain? _____ If so, please list
dates of operations.
____________________________________________________________________________
____________________________________________________________________________
______________________

23. Did any of the operations help? _____ If so, which ones, and how long
did they help? ______________________________________________
____________________________________________________________________________
________________________________________


24. List all medications (both prescription and non-prescription) which you
are taking; include the name of the medication, its dosage, and how often
you take it.
____________________________________________________________________________
____________________________________________________________________________
______________________

25. Do any of these medications alleviate your pain? _____ If so, specify
which ones work and for how long each works.
____________________________________________________________________________
____________________________________________________________________________
______________________


26. Have you ever had any nerve blocks for pain? _____ If so, give the
dates. ____________________________________________________

27. Did any of these infections bring relief? _______________________
__________________________________________________________


28. Who prescribed the nerve blocks? ____________________________
__________________________________________________________


29. Have you ever used a TENS unit for pain? ____ If so, who
prescribed it for you? ________________________________________
__________________________________________________________


30. Did the TENS unit provide relief? ____________________________

31. Prior to this injury, did you ever experience any severe pain over a
period of time? _____________________________________________

32. If so, please give the circumstances and dates.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____


33. Did you consider yourself a "sickly" person? _____

34. What is your current treatment? _____________________________
____________________________________________________________________________
____________________________________________________________________________
______________________


35. What do you expect from your treatment? ______________________
____________________________________________________________________________
________________________________________


36. Do you think your treatment plan is working? _____


37. Do you think your treatment plan is helping to alleviate your pain?
__________________________________________________________


38. Are you satisfied with your doctors and your treatment plan? _____
If not, what changes would you like to make?
____________________________________________________________________________
________________________________________


39. Have you ever had any psychological treatment for your pain? _____ If
so, when and from whom? ____________________________________
____________________________________________________________________________
________________________________________


40. Have you ever had any psychological treatment for any other condition
or problem? _____ If so, when and from whom?
____________________________________________________________________________
________________________________________

41. Has the pain interfered with your social life? _____ If so, be as
specific as possible in describing any activities or hobbies in which you
can no longer participate or which you can no longer enjoy.
____________________________________________________________________________
________________________________________

42. Did you consider yourself an active and energetic person before your
injury and the resulting pain? _____

43. Are there any activities or hobbies you still enjoy? _____ What are
they and to what extent can you still participate in them?
____________________________________________________________________________
____________________________________________________________________________
______________________


44. Do you have any desire to participate in social or recreational
activities? _____ If not, why don't you have the desire?
____________________________________________________________________________
____________________________________________________________________________
______________________

45. Has the pain and injury affected your sexual activities? _____
If so, please explain. _____________________________________
____________________________________________________________________________
____________________________________________________________________________
______________________

46. Does talking about your pain and injury help in any way? _____
If so, please explain. _________________________________________
____________________________________________________________________________
____________________________________________________________________________
______________________

47. Are you receiving any counseling for your pain? _____ If so, from
whom? ____________________________________________________
____________________________________________________________________________
________________________________________


48. Do you consider yourself to be an irritable and impatient person?
_____

49. How often do you get angry? ________________________________

50. Do you feel that your anger or irritability is associated with your
pain? _____________________________________________________

51. Do you feel that your pain is causing you to have emotional
difficulties? _____ If so, explain. ______________________________
__________________________________________________________


52. How does your spouse react to the pain? _______________________
____________________________________________________________________________
________________________________________

53. How do your children react to the pain? _______________________
____________________________________________________________________________
________________________________________


54. How do your friends react to the pain? ________________________
____________________________________________________________________________
_______________________________________


55. What was your general outlook on life before the injury and pain?
__________________________________________________________
____________________________________________________________________________
________________________________________

56. What is your general outlook on life now? ______________________
____________________________________________________________________________
________________________________________

57. Do you ever feel that your situation is hopeless? _____ If so, what do
you think can be done to remedy this feeling?
_______________________________________________________________________


58. Do you consider that you have a positive outlook with respect to your
injury and pain? _____ If not, what can you do or what can be done to
achieve a positive outlook?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____

59. What do you think is the cause of your pain? ____________________
____________________________________________________________________________
________________________________________

60. What do you feel can be done to alleviate your pain? ______________
____________________________________________________________________________
________________________________________

61. What do you feel that your attorney can do to help?
__________________________________________________________
__________________________________________________________

62. With respect to your pain and injury, what do you expect from your
attorney in this case? ________________________________________
____________________________________________________________________________
____________________________________________________________________________




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Since 1985, KENNETH VERCAMMEN has worked as a personal injury attorney, working for injury victims and their families. By taking a hard-hitting, aggressive approach toward the insurance companies, KENNETH VERCAMMEN and our co-counsel have consistently obtained outstanding results for many injured clients over the years I am proud to have worked on cases in various capacities, small and large. While obviously prior results cannot guarantee the outcome of future cases, I can guarantee that you case will receive the same degree of dedication and hard work that went into each of these prior cases.

In direct contrast to the hard-hitting approach we take toward the insurance companies is the “soft” approach we take toward our clients. I am proud of my compassionate staff as I am of the outstanding financial results they have achieved. For many years, I have watched them treat our clients with patience, dignity and respect. I would have it no other way.

Many years ago, I attended a seminar sponsored by the American Bar Association on Law Practice Management. This was to help insure that each of our clients is always treated like a person -- not a file! We recognize that you are innocent victims and that you have placed your trust in us. Please understand that we understand what you are going through. Feel comforted that we are here to help you.

If you retain KENNETH VERCAMMEN to represent you, we will give you the same advice we give each of our clients -- concentrate on your life, you family and your health. We will take care of everything else. Leave all of the work and worry about your legal rights to us. Trust us. Believe in us. Have faith in us as your attorneys. Understand that we will always to do what we believe is best for you and your case. Helping you is our job. In fact, it is our only job -- guiding injury victims like you through one of the most difficult times of your lives, with care and concern -- while fighting aggressively to the limits of the law to obtain compensation and justice for each of you!

Print our Personal Injury Questionnaire on our Website, Fill it out and Fax back, so we can determine if we can help you obtain an injury settlement. We would welcome an opportunity to prove to you what we have proven to thousands of injured clients -- that you can feel comfortable and secure in the fact that KENNETH VERCAMMEN - Trial Attorney We Fight To Win.

When you have been injured in an accident or collision, you are worried about who is going to pay your medical bills, lost wages, and other damages. The last thing you want is to be taken advantage of by an insurance company. If you don’t protect your rights, you may not be able to make a claim.

Insurance companies have attorneys and adjusters whose goal is to pay you as little as they can. You need a New Jersey personal injury lawyer to fight for you. I am dedicated to helping your recover as much money as possible under the law.

You need an attorney who will work hard to protect your rights, maximize your insurance settlement and minimize the hassles of dealing with the insurance companies. You need an experienced and aggressive New Jersey trial lawyer with PROVEN RESULTS who will fight for you. Having an experienced Oregon personal injury lawyer can make the difference between getting what you deserve and getting nothing.

Without the threat of a lawyer who is willing to go to trial and seek a big jury verdict, why would an insurance company pay you what your claim is really worth? Lawsuits can be expensive, and many people do not have the money to pursue their claim. In every case, I advance all costs associated with pursuing your case and I do not ask you for a penny until we recover from the other side.

I am an experienced aggressive trial lawyer and a 3rd degree Black Belt. I am not afraid to take your case to trial if that is what it takes to maximize the amount of money your recover for your personal injury. I offer one-on-one service, and I will not hand your case off to an inexperienced lawyer or a paralegal.

Reduce the stress of making a claim.

Personal injury accidents can turn your life upside down. Making a personal injury claim can be difficult and time consuming. Once I take your case, you can stop worrying about dealing with the insurance companies and focus on recovering from your injuries. I take care of all of the paperwork, phone calls, and negotiations, so you can get on with your life.

p.s. For those clients who are afraid or reluctant to go to Court, KENNETH VERCAMMEN also offers a special -- “For Settlement Only” -- program. This means that if we are unable to settle with the insurance company, we will not go any further -- unless you want us to. You have my personal assurance that there will be absolutely no pressure and no obligation.

We handle personal injury cases on a contingency fee basis.

This means:
YOU DON’T OWE ME A LEGAL FEE UNLESS I RECOVER MONEY FOR YOU.

Call our office to schedule a "confidential" appointment 732-572-0500

Kenneth A. Vercammen is the Managing Attorney at Kenneth Vercammen & Associates in Edison, NJ. He is a New Jersey trial attorney has devoted a substantial portion of his professional time to the preparation and trial of litigated matters. He has appears in Courts throughout New Jersey each week on personal injury matters, Criminal /Municipal Court trials, and contested Probate hearings.

Mr. Vercammen has published over 125 legal articles in national and New Jersey publications on criminal, elder law, probate and litigation topics. He is a highly regarded lecturer on litigation issues for the American Bar Association, NJ ICLE, New Jersey State Bar Association and Middlesex County Bar Association. His articles have been published in noted publications included New Jersey Law Journal, ABA Law Practice Management Magazine, and New Jersey Lawyer. He is the Editor in Chief of the American Bar Association Tort and Insurance Committee Newsletter.

Admitted In NJ, NY, PA, US Supreme Court and Federal District Court.

Contact the Law Office of
Kenneth Vercammen & Associates, P.C.
at 732-572-0500
for an appointment.

The Law Office cannot provide legal advice or answer legal questions over the phone or by email. Please call the Law office and schedule a confidential "in office" consultation.